Enhanced recovery following hip and knee arthroplasty: A systematic review of cost-effectiveness evidence

Mark Pritchard, Jacqueline Murphy, Lok Cheng, Roshni Janarthanan, Andrew Judge, José Leal

Research output: Contribution to journalArticle (Academic Journal)peer-review

13 Citations (Scopus)
74 Downloads (Pure)


Objectives: To assess cost-effectiveness of enhanced recovery pathways following total hip and knee arthroplasties. Secondary objectives were to report on quality of studies and identify research gaps for future work.

Design: Systematic review of cost–utility analyses.

Data Sources: Ovid MEDLINE, Embase, the National Health Service Economic Evaluations Database, and EconLit, January 2000 to August 2019.

Eligibility Criteria: English-language peer-reviewed cost–utility analyses of enhanced recovery pathways, or components of one, compared to usual care, in patients having total hip or knee arthroplasties for osteoarthritis.

Data extraction and synthesis: Data extracted by three reviewers with disagreements resolved by a fourth. Study quality assessed using the Consensus on Health Economic Criteria (CHEC) list, the International Society for Pharmacoeconomics and Outcomes Research (ISPOR) and Assessment of the Validation Status of Health-Economic (AdViSHE) decision models tools; for trial-based studies the Cochrane Collaboration’s tool to assess risk of bias. No quantitative synthesis was undertaken.

Results: We identified 17 studies: five trial-based and 12 model-based. Two analyses evaluated entire enhanced recovery pathways and reported these to be cost effective compared to usual care. Eleven pathway components were more effective and cost-saving compared to usual care, two were cost-effective, and two were not cost-effective. We had concerns around risk of bias for all included studies, particularly regarding the short time horizon of the trials and lack of reporting of model validation.

Conclusions: Consistent results supported enhanced recovery pathways as a whole, prophylactic systemic antibiotics, antibiotic-impregnated cement and conventional ventilation for infection prevention. No other interventions were subject of more than one study. We found ample scope for future cost-effectiveness studies, particularly analyses of entire recovery pathways and comparison of incremental changes within pathways. A key limitation is that standard practices have changed over the period covered by the included studies.

Registration: International Prospective Register of Systematic Reviews: CRD42017059473
Original languageEnglish
Article numbere032204
Number of pages12
JournalBMJ Open
Issue number1
Publication statusPublished - 15 Jan 2020


  • cost-effectiveness
  • economic evaluation
  • hip replacement
  • knee replacement
  • osteoarthritis
  • systematic review


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